Sunday, August 28, 2016

listen up

Storytelling isn’t easy. Even the best authors sometimes struggle to put their ideas into words, and emotions can be hard to express.  Ask any writer.

So it shouldn’t come as a surprise that patients have trouble telling the stories of their illnesses. When they try to tell us about their symptoms, they may not have the language for it. The fellow having a heart attack may describe his pain as indigestion, when the doctor is looking for words like dull, heavy, or tight to describe the discomfort. The patient who is lightheaded may  describe the feeling as dizziness rather that fainting. The provider then has to determine if the patient is experiencing presyncope or vertigo. The patient who complains about pain in his sinuses may be experiencing a migraine headache. Patients don’t know what we need to hear from them about their symptoms, so sometimes the obstacle is language.

Sometimes the problem is denial. The fellow having the heart attack may know exactly what is happening to him, but be so scared by the prospect he unconsciously tries to make a case for something less ominous. He describes his problem as indigestion, hoping the doctor will say, "It sounds like reflux. Nothing too serious."

Fear, then, is another confounding factor. When a patient describes a symptom, the provider has a long list of details he needs to know in order to diagnose the cause of the patient’s distress. However, the patient might be more frightened by the symptom than he is suffering from its severity. Perhaps a coworker recently suffered a disabling stroke. The patient is having some tingling in his right hand so he’s convinced he’s about to have a stroke, too. Carpal tunnel syndrome doesn’t cross his mind. The tingling isn’t severe, but his fear of having a stroke is off the charts. Once the doctor addresses the patient’s unfounded fears, treatment has a better chance of success.

It’s up to the provider to figure out what is what. This explains why health care providers must be excellent listeners. We have to make an accurate diagnosis by listening clinically, and we must understand how the illness affects the patient by listening empathetically.

Listening clinically involves getting the details right. Encouraging the patient to tell us about the onset of his symptoms (sudden or gradual), the duration (hours, days or months), the severity (mild or excruciating), and quality (sharp or dull, constant or intermittent, localized or generalized). A thorough and accurate history of the patient’s symptoms is fundamental to making an accurate diagnosis.

But there’s more to it than that. Empathetic listening enables us to understand how the illness affects the patient, what it means to him, and why. Why is he in denial? What is he afraid of? How will his illness affect his job, his family, his faith? It includes:

  • Reading facial expressions and body language. For instance, if the patient brings his fist to his chest when he is telling you about his heartburn, you need to think heart attack instead. It’s a classic gesture. 

Image result for patient describing a heart attack with clenched fist in chest

  • Understanding the patient’s emotional state. I once had a young woman come in with a swollen black eye. She laughed it off. “I’m so clumsy,” she said. “I was jumping on the bed and hit my eye on the corner of the TV.” In fact, she had a blowout fracture of the floor of the eye socket. When I asked her what really happened, she described the blow she took from her boyfriend’s fist, the fear she felt for her life. She not only needed medical care, she needed social services.
  • Listening between the lines for what the patient may be leaving out. I used to ask my teenage patients whether or not they were sexually active. Invariably, the answer was, “No.” That let me off the hook. I didn’t have to ask about STDs or contraceptive practices. It saved time…but I knew it wasn’t always true. So I started to ask instead, “How many sex partners have you had?” Eight, twelve, twenty-five! I was flabbergasted. But it enabled me to begin a meaningful discussion about body image and the patient's sense of self-respect. We went over the dangers of and prevention of STDs. And I was able to offer reliable contraception. 
What difference does empathetic listening make? It gets us closer to the truth. It connects us with our patients in a meaningful way. It improves patient satisfaction and that by itself helps promote healing. It enhances diagnostic accuracy and the efficacy of treatment. It decreases the physician’s sense of frustration and ineffectiveness. And by strengthening the physician-patient bond, it decreases the rate of physician burnout.

If good storytelling is an art, effective listening is a craft. In these efforts the physician-patient partnership is forged. Health care becomes a mutual endeavor, and everyone benefits from it.
“You are so brave and quiet
I forget you are suffering.”
~Ernest Hemingway~

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